Federal Policy Update

1. Federal Policy Update 2009 OACCA Advocacy Conference

2. The Landscape in Washington: • A New President • New Makeup in Congress: • SENATE: 56 D; 41 R; 2 Independent; 1 still vacant (MN election being contested) • HOUSE: 254 D; 178 R; 3 still vacant (Solis, Gillibrand, Emanuel) • New Congressional Committee Makeup: • Rep. Henry Waxman now Chairs the House Energy and Commerce Committee • Rep. Danny Davis now on House Ways and Means Subcommittee on Income Security and Family Support • New HHS Secretary to be Confirmed, Gov. Kathleen Sebelius What does this mean for YOU and the children and families you serve?....

3. A lot of work…. but more importantly…. …a lot of OPPORTUNITY!

4. Today, a Brief Overview of: • Medicaid regulations and the Medicaid Services Restoration Act • Health provisions of the economic recovery package (now law) • Other important provisions of the economic recovery package that will help children and families (now law) • CHIP reauthorization (now law) • Mental health and addiction parity (now law) • Health reform • Federal Budget • Fostering Connections Act (now law) • Prevention initiatives • Juvenile Justice initiatives • Child Welfare Workforce initiatives • Education initiatives • White House Conference on Children & Youth

5. Medicaid Regulations • The Bush Administration issued a series of Medicaid regulations that in the aggregate, would devastate our nation’s health safety net. • Two of Major Concern to the Child Welfare and Foster Care Communities: Rehabilitative Services and Targeted Case Management (TCM) • The rehab and TCM rules would: • Take away significant Medicaid funding for these services, shifting the cost to child welfare and foster care ($2.2 billion/5 yrs from rehab option and $1.28 billion/5 yrs from TCM option); • Require TCM services to be billed in increments ≤ 15 minutes; and • Require TCM services to be billed by a single case manager Status: • Rehab is delayed until April 1, 2009 (P.L. 110-252, Supplemental Appropriations Act) • TCM is delayed until June 30, 2009 (P.L. 111-5, American Recovery and Reinvestment Act) • “Sense of the Congress” in recovery package that rehab reg should be withdrawn

6. Medicaid Services Restoration Act • The “Back Up”….and Potentially More • The Act Would: • Create a new medical assistance category for therapeutic foster care (TFC) • Allow states to use bundled rates for rehab or TCM services • Allow non-medical programs (child welfare, foster care, etc) to continue drawing down Medicaid funds for rehab and TCM services, as long as they are offered by qualified providers and the state/local agency is complying with in-place third party liability rules • Clarify that medical/surgical services for children in 24 hour psychiatric hospitals and PRTFs are Medicaid-reimbursable (in line with EPSDT) • Allow states to use multiple case managers when necessary Status: • Was introduced by Senator Debbie Stabenow (D-MI) in the 110th Congress • Will likely be re-introduced by Sen. Stabenow; companion bill in House

7. Health Provisions of Recovery Package • Medicaid regs (discussed above) • 65% subsidy for unemployed workers to continue purchasing COBRA coverage for up to 9 months • Extends Transitional Medical Assistance (TMA) through December 31, 2010

8. Medicaid FMAP Provision of Recovery Package • $87 billion total • 6.2% increase to all states and territories as long as state maintains eligibility as it existed on July 1, 2008 • 65% distributed across the board; 35% distributed to states experiencing particularly high unemployment • Funding retroactive to October 1, 2008 and through December 31, 2010 • More info on FMAP Provision: http://hhs.gov/recovery/statefunds.html and http://www.cbpp.org/2-13-09sfp.pdf

9. Other Provisions in the Recovery Package that Will Benefit Children and Families • Title IV-E:6.2% increase to Title IV-E foster care maintenance payments and adoption/kinship assistance (not administrative costs) • CCDGB: $2 billion for Child Care Development Block Grant (CCDBG) (funding to subsidize child care for children in low-income working families and low-income families in which parents are engaged in education or training) • TANF: $5 billion for Temporary TANF, to help states with rising caseloads • Head Start: $1.1 billion for Early Head Start and $1 billion for Head Start (comprehensive development services to low-income infants and preschool children)

10. Other Provisions in the Recovery Package that Will Benefit Children and Families • Food Stamps: $20 billion for the Food Stamp/Supplemental Nutrition Assistance Program • Child Tax Credit (CTC): $14.8 billion for the Child Tax Credit (CTC). Temporarily expands the Child Tax Credit by lowering the eligibility level to tax filers with at least $3,000 of earnings (prior law, credit was only available to those with earnings of $8,500 or more in tax year 2008 and $12,550 in tax year 2009) Status: • Signed into law February 17, 2009 (P.L. 111-5) • At least $15 billion of the Medicaid FMAP funds released starting February 25. State breakdown can be viewed: http://hhs.gov/recovery/statefunds.html. • Other provisions’ funding such as child care is pending; will be spread out over two years.

11. More Info on Recovery Package: • Center on Budget and Policy Priorities Paper with State-by-State Estimates of Provisions Impacting Low-Income Americans: http://www.cbpp.org/1-22-09bud.pdf • Coalition on Human Needs Chart: http://chn.org/pdf/2009/ConfEconRecoveryChart21709.pdf • http://www.recovery.gov/

12. CHIP Reauthorization • $32.8 billion additional • In human terms, this maintains enrollment for 7 million and provides coverage for 4.1 million more children • Important New Provisions: • State option to lift 5 year waiting period that legal immigrant children and pregnant women currently face to enroll in Medicaid or CHIP • Mental health parity • Dental. Children in private coverage w/out dental can get wraparound through CHIP. • State option to implement express lane eligibility. • Performance bonuses to states that exceed enrollment baselines for children in Medicaid and implement certain enrollment practices • $100 million in grants available for outreach and enrollment

13. CHIP Reauthorization (cont.) • Citizenship Documentation: State option to use SSN to verify citizenship prior to enrolling in Medicaid or CHIP. • Quality: Creates a Medicaid Payment Advisory Commission to examine access and provider payment issues in Medicaid. • Eligibility for Children: • States already above or with approval to go above 300% FPL will still receive enhanced federal match for these children • New states going above 300% will receive regular Medicaid match Status: • Signed into law February 4, 2009 (P.L. 111-3) • Next day, rescinded the August 17, 2007 policy directive restricting states’ ability to cover children over 250% FPL

14. Mental Health & Addiction Parity • Requires group health plans with 50 or more enrollees who choose to offer mental health and addiction benefits to provide them on the same terms as other medical conditions. • Prohibits such insurers from setting higher financial limitations (deductibles, copayments, coinsurance, and out-of-pocket expenses) or lower limits on treatment for mental and addiction illnesses. • Requires equal out-of-network benefits. • Does NOT preempt stronger state parity laws.

15. Parity (cont.) Parity Law is Significant Because: • Estimated that it will help at least 113 million Americans receive easier access to treatment. These may be families on the verge, who with proper treatment, can safely remain together and out of the system. • Over 10 years in the making… • Hopefully shows that the stigma associated with mental illness is decreasing and people understand that quality treatment works. • Applies to Medicaid managed care plans; new CHIP law requires parity in CHIP. Status: • Signed into law on October 3, 2008 as part of economic “bailout” • Guidance will follow

16. Health Reform • Even with recession, many are saying we cannot wait. Must reign in ineffective spending and make significant progress towards covering more of the nearly 46 million uninsured Americans. • Obama would like to cover all children. CHIP was a “down payment.” • Contours are still TBD, but will likely build on existing programs and coverage options. Status: • Discussions happening now. Key players include Sens. Kennedy, Baucus, Grassley, Enzi and Reps. Dingell, Waxman, Barton, Pallone, Deal, Rangel and Stark. • Baucus would like a bill on the Senate floor by the Summer; others skeptical. • $630 billion/10 years reserve fund in FY 2010 budget for health reform.

17. Federal Budget FY 2009 Omnibus (H.R. 1105): • Nine appropriations bills unfinished from last year (all except DOD, Homeland Security, and Veterans Affairs) • $410 billion, $19 billion more than Bush proposed • Small boosts to: Child care, Head Start • Status:Passed the House Feb. 25; in the Senate FY 2010: • February 26, President Obama released his FY 2010 budget outline • Key Portions: • Over $630 billion/10 years for health reform • $1.1 billion for Early Head Start; $1 billion for Head Start • Over $80 million in 2010 for nurse home visitation • Makes permanent the expansion of the Child Tax Credit

18. Fostering Connections Act • Kinship Care • State option to use federal Title IV-E funds for kinship guardianship payments for children raised by relative caregivers • To qualify, children must: • be eligible for federal foster care maintenance payments • reside with the relative for at least six consecutive months in foster care • Be likely to otherwise remain in foster care until they aged out of the system

19. Fostering Connections Act • Kinship Care (cont.) • State agencies must identify and provide notice to all adult relatives of a child within 30 days after the child is removed from the custody of the parent(s). • Kinship payment rate may equal but cannot exceed what would have been the foster care payment • States may waive non-safety licensing standards (as determined by the state) on a case-by-case basis in order to eliminate barriers to placing children with relatives. HHS must submit a report on states’ use of waivers within 2 years.

20. Fostering Connections Act Tribal • Option for tribes or tribal consortia to directly access and administer IV-E by submitting a plan to HHS • Takes effect on October 1, 2009 (FY 2010). • Transition Age Youth • State option to extend care to youth age 19, 20, or 21 as long as youth are involved with education, employment, or unable to do either due to a medical condition. Option can begin on October 1, 2010 (FY 2011). • Child welfare agencies must help youth develop a transition plan during the 90-day period immediately before a youth exits from care at 18, 19, 20, or 21

21. Fostering Connections Act Adoption • De-links federal adoption assistance from the now non-existent AFDC program. Gradually phased in. Some populations covered right away: • Special needs adoptions over age 16; all special needs covered by year 10. • Siblings of eligible children also eligible right away. • Children in foster care for 5+ consecutive years also eligible right away. • Adoption Incentives Program reauthorized for 5 years: • States get additional $1000/adoption if rate exceeds highest foster child adoption rate since 2002. • $8000 additional per older child adoption (9 years +) • $4000 additional per special needs adoption

22. Fostering Connections Act Health • State child welfare agency must work with the state Medicaid agency (and other healthcare experts) to create a plan for the ongoing oversight and coordination of health care services for children in foster care. • Medicaid agency is NOT relieved of its duty to provide care. • Plan must include: • health screening and follow up screenings; • how needs will be identified and addressed; • how medical information will be updated and shared; • steps taken to ensure continuity of care including the possible use of medical homes for each child; • oversight of prescription medication; and • how the state consults with medical and nonmedical professions on the appropriate treatment of children.

23. Fostering Connections Act Status: • Signed into law on October 7, 2008 • Still a lack of clarity in regard to guidance and likely to be that way until more HHS positions are filled. • Congressional staff indicated at our conference that some Children’s Bureau guidance was too narrow. More Info: • http://www.cwla.org/advocacy/adoptionhr6893.htm

24. Prevention Initiatives • Education Begins at Home Act (EBAH): • Would establish the first dedicated federal funding stream solely for evidence-based, quality, voluntary home visiting programs for parents with young children • Governor would designate a lead state agency to oversee and implement the state program • States can use their grants to supplement—but not replace—current state funding • State's grant funding award would be based on the number of children 5 and younger living in the state • Fully fund programs such as PSSF, CAPTA, Title V Maternal and Child Health Block Grant, SSBG • Use Fostering Connections to expand family group decision making; use IV-E training funds for training court personnel in prevention and intervention programs Status: • EBAH: • Senate bill introduced by Sen. Bond (R-MO) and Sen. Murray (D-WA), S. 244 • House bill likely to be re-introduced shortly • Others have been recommended to the new Administration and Congress

25. Juvenile Justice and Delinquency Prevention Act • Federal initiative designed to assist state and local governments and private nonprofit agencies in supporting and initiating programs that prevent and treat juvenile delinquency. • Encourages states to coordinate and integrate the juvenile justice and child welfare systems to improve outcomes for children and reduce delinquency. • Established in 1974 and most recently authorized in 2002. Status: • Senate bill in the last Congress (S. 3155) passed Senate Judiciary Committee. It is expected this Committee will do so again soon. • This bill builds on the coordination between the child welfare and juvenile justice systems, and is more specific in improving protocols and procedures between these systems.   • The House has not yet acted on this reauthorization.

26. Youth PROMISE Act • Provides federal resources for local, community-based strategies to reduce gang violence and crime. • Local councils will develop a comprehensive plan for implementing evidence-based prevention and intervention strategies. These strategies will be targeted at young people who are at-risk of becoming involved, or involved in, gangs or the criminal justice system to redirect them toward productive and law-abiding alternatives.  • Funding will be made available to implement these strategies. Status: • Legislation has been introduced with bi-partisan support in both the House and Senate: H.R. 1064, S. 435. • Hearings are expected to begin soon.

27. Workforce Initiatives • Keeping qualified workers on the job and reducing turnover • Loan Forgiveness • In 2008 as part of the Higher Ed Act, up to $2,000/year for child welfare workers at public or private agencies for each of the first 5 years the worker remains at the agency. • Status:Law, Congress must appropriate the funding. Department of Ed must issue regs. • Training Funds: • In 2008 as part of the Fostering Connections Act, training funds opened to private agencies and court- and child welfare-related employees including CASAs and GALs • Status:Law, regulations to be issued. Hopeful that these will broadly interpret and allow states to leverage funds and strengthen the workforce. • Other Funding: • Should increase the $7 million in Title IV-B, part 1 training funds to strengthen the child welfare workforce • Should increase the $20 million in PSSF (Title IV-B, part 2) for workforce improvement

28. Education & Children in Care • Belief that a child placed in foster care should be permitted to attend the school at which s/he is most comfortable • Fostering Connections Act: • Case plan must take into account the stability of the current educational setting • Child welfare agency must coordinate with local education agency so that child remains in the school where s/he is enrolled at the time of foster placement. If not in the best interest of the child to remain at the same school, child must be enrolled immediately at an appropriate new school • Status: Guidance will be issued. Foster care maintenance payments can be used for transportation.

29. White House Conference on Children & Youth • Issues to be addressed include: permanency, health and mental health care, education, substance abuse, housing, juvenile justice, workforce issues, tribal access and services, strategies to help families, and strategies to prevent abuse • CWLA is leading the call to re-establish a White House Conference on Children & Youth in 2010, focused on child welfare. • President Theodore Roosevelt called the 1st conference in 1909 and one was held every 10 years, until 1970 • There is an actual conference attended by delegates, governors, and the policy committee, but the truly important part is the time leading up to the conference. State and local meetings that bring together state agencies, advocates, experts, policymakers, and children youth and families

30. White House Conference on Children & Youth • Status: • House bill introduced, H.R. 618, by Rep. Chaka Fattah (D-PA) and Rep. Todd Platts (R-PA). 43 sponsors thus far, including 7 added after CWLA’s Advocacy Day. • Senate bill will likely be re-introduced shortly More Info and to Sign Up in Support: http://www.cwla.org/advocacy/whitehouseconf10.htm

31. Questions?? Health: Laura Weidner, lweidner@cwla.org Fostering Connections, Economic Recovery: John Sciamanna, jsciamanna@cwla.org Prevention: YaMinco Varner, yvarner@cwla.org Juvenile Justice: Tim Briceland-Betts, bricebet@cwla.org White House Conference: Cristina Fahrenthold, cfahrenthold@cwla.org